Failure to Remove Staff from Resident Care Following Substantiated Abuse Allegation
Summary
A resident with diagnoses including Parkinsonism, dysphagia, and cognitive communication deficit, who was cognitively intact according to a BIMS score of 14, alleged that during the midnight shift, a nurse physically abused her while providing incontinence care. The resident reported that she accidentally kicked the nurse out of fear of falling, after which the nurse hit her on the left upper arm and told her she would have to wait for the day shift to finish her care. The resident expressed feeling safe in the facility overall but requested not to have the same nurse assigned to her in the future. The facility conducted an investigation into the incident, interviewing both the resident and the nurse involved. The nurse denied the allegations, stating she did not provide any ADL care to the resident and only interacted with her during medication administration, further claiming the resident was confused. Despite this, the facility substantiated the allegation based on the resident's consistent account, cognitive status, and lack of prior false allegations. The facility's documentation indicated that the nurse received a final written warning for confirmed verbal, physical, or emotional abuse, rudeness, and negligence toward the resident. Despite the substantiated abuse allegation and the resident's request, the nurse continued to be assigned to the resident and provided care, including medication administration, on multiple occasions after the incident. The administrator was unaware that the nurse had continued to care for the resident and acknowledged that this was not in line with facility policy, which states that staff involved in abuse allegations should be immediately removed from contact with the resident pending investigation. The facility's own abuse policy requires immediate protective actions to prevent further harm, which were not followed in this case.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.